Isolated Subtalar Arthrodesis: Treating Subtalar Arthritis While Preserving Ankle Motion

Quick answer: Treatment for isolated subtalar arthrodesis treating subtalar arthritis preserving ankle follows a stepwise approach: 1) conservative care first (rest, ice, supportive footwear, OTC anti-inflammatories), 2) physical therapy and targeted exercises, 3) in-office treatments (injections, custom orthotics) if conservative fails at 4-6 weeks, 4) surgery for refractory cases. Most patients resolve at step 1 or 2. Call (810) 206-1402.

Medically reviewed by Dr. Tom Biernacki, DPM — Board-Certified Podiatric Surgeon — Balance Foot & Ankle, Howell & Bloomfield Hills, MI. Last updated April 2026.

🩺 Medically Reviewed by Dr. Tom Biernacki, DPM, FACFAS — Board-Certified Podiatrist
Balance Foot & Ankle Specialists | Southeast Michigan

Quick Answer: Isolated Subtalar Arthrodesis

Isolated subtalar arthrodesis (fusion) permanently joins the talus and calcaneus to eliminate painful motion in the subtalar joint while preserving ankle and midfoot motion. Success rates exceed 90% for pain relief with proper patient selection. Most patients return to full weight-bearing at 8-12 weeks and achieve maximum improvement by 12 months. Modern fixation techniques and careful surgical planning minimize complications and preserve functional hindfoot alignment.

📑 Table of Contents

1. Subtalar Joint Anatomy and Function
2. When Subtalar Fusion Is Recommended
3. Causes of Subtalar Arthritis
4. Conservative Treatment Before Surgery
5. Surgical Technique
6. Fixation Methods
7. Bone Grafting Considerations
8. Recovery Timeline
9. Weight-Bearing Progression
10. Physical Therapy Protocol
11. Clinical Outcomes and Success Rates
12. Expected Motion Changes
13. Potential Complications
14. Nonunion Management
15. Adjacent Joint Protection
16. Long-Term Results and Function
17. Recommended Recovery Products
18. Most Common Mistake
19. Warning Signs After Surgery
20. Frequently Asked Questions

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Subtalar Joint Anatomy and Function

The subtalar joint sits directly below the ankle joint, formed by the articulation between the inferior surface of the talus and the superior surface of the calcaneus (heel bone). Despite its relatively small size, this joint plays a critical role in foot function — it is the primary joint responsible for inversion and eversion, the side-to-side rocking motion that allows your foot to adapt to uneven terrain.

The subtalar joint has three articular facets (anterior, middle, and posterior) separated by the tarsal canal and sinus tarsi. The posterior facet is the largest and bears the greatest load — it is also the most commonly affected by arthritis. The interosseous talocalcaneal ligament and cervical ligament within the sinus tarsi provide primary stability to the joint.

Normal subtalar motion is approximately 20-30 degrees of inversion and 5-10 degrees of eversion. When functioning properly, this motion occurs seamlessly during walking, allowing the foot to be a flexible adaptor at heel strike and a rigid lever at push-off. When arthritis destroys this joint, the resulting pain and stiffness fundamentally impairs gait mechanics.

Understanding this anatomy helps explain why isolated subtalar fusion — while eliminating subtalar motion — still preserves the majority of functional foot motion through the ankle joint (dorsiflexion/plantarflexion) and the transverse tarsal joints (Chopart’s joint) that provide compensatory adaptation.

When Subtalar Fusion Is Recommended

Isolated subtalar arthrodesis is indicated when conservative treatment has failed to adequately manage pain from subtalar arthritis. The most common indications include post-traumatic arthritis (particularly after calcaneal fractures), primary osteoarthritis, rheumatoid arthritis, posterior tibial tendon dysfunction with subtalar involvement, tarsal coalition with secondary arthritis, and residual deformity from untreated or malunited fractures.

The decision to proceed with fusion requires a careful assessment of the adjacent joints — particularly the ankle and talonavicular joints. If these joints also show significant arthritis, a more extensive procedure (such as triple arthrodesis) may be more appropriate. Isolated subtalar fusion is specifically indicated when the subtalar joint is the primary or sole source of pain.

Patient selection is critical. The ideal candidate has failed at least 6 months of conservative treatment including bracing, orthotics, injections, and activity modification, has imaging that confirms significant subtalar arthritis, has minimal adjacent joint disease, and understands the expected outcomes including permanent loss of subtalar motion.

Causes of Subtalar Arthritis

Post-traumatic arthritis is by far the most common cause, accounting for 60-70% of cases. Calcaneal (heel bone) fractures — particularly intra-articular fractures that disrupt the posterior facet — have a 50-70% rate of developing post-traumatic subtalar arthritis within 5-10 years, regardless of treatment method. Falls from height and motor vehicle accidents are the most common injury mechanisms.

Primary osteoarthritis of the subtalar joint is relatively uncommon compared to the knee or hip, but does occur, particularly in patients with longstanding biomechanical abnormalities such as severe flatfoot, cavus foot, or limb length discrepancy that creates asymmetric loading of the subtalar joint over decades.

Inflammatory arthritis including rheumatoid arthritis, psoriatic arthritis, and gout can affect the subtalar joint. Rheumatoid arthritis in particular has a predilection for the hindfoot joints and may cause progressive deformity with valgus collapse that worsens if not addressed surgically.

Tarsal coalition — an abnormal bony, cartilaginous, or fibrous connection between tarsal bones — can lead to secondary subtalar arthritis as compensatory motion stresses the joint surfaces. Talocalcaneal coalition (the most common type) directly involves the subtalar joint and may present with painful symptoms beginning in adolescence or early adulthood.

Conservative Treatment Before Surgery

Before considering subtalar fusion, patients should complete a comprehensive trial of conservative management lasting at least 6 months. This establishes that non-surgical options have been exhausted and provides a baseline for measuring surgical improvement.

Bracing and orthotics: A rigid or semi-rigid ankle-foot orthosis (AFO) or a University of California Biomechanics Laboratory (UCBL) orthotic can significantly limit subtalar motion and reduce pain. Custom orthotics with a deep heel cup and medial posting correct alignment and reduce pathological stress across the arthritic joint surfaces. Over-the-counter arch support insoles can provide initial relief while custom devices are being fabricated.

Injections: Corticosteroid injections into the subtalar joint — performed under fluoroscopic or ultrasound guidance for accuracy — can provide 6 weeks to 6 months of pain relief and serve as a diagnostic confirmation that the subtalar joint is the pain source. If an injection provides significant temporary relief, it strongly supports the diagnosis and predicts a favorable surgical outcome.

Activity modification: Avoiding impact activities, wearing supportive footwear with cushioning, using a cane for longer walks, and substituting cycling or swimming for walking exercise can maintain fitness while reducing subtalar loading.

Surgical Technique

Isolated subtalar arthrodesis is typically performed through a lateral oblique incision centered over the sinus tarsi — the natural depression between the ankle bone (lateral malleolus) and the heel. This extensile approach provides excellent visualization of the posterior facet while preserving the sural nerve and peroneal tendons.

The procedure begins with removal of all remaining articular cartilage from the posterior facet (and anterior/middle facets if involved) using a combination of osteotomes, curettes, and power instruments. The subchondral bone is fenestrated (drilled with small holes) to expose bleeding cancellous bone, creating a vascular surface that promotes fusion.

Joint alignment is critically important. The calcaneus is positioned in approximately 5 degrees of valgus (slight outward tilt) relative to the tibial axis, which preserves the normal heel alignment necessary for efficient gait. Excessive valgus creates lateral impingement pain, while varus positioning (inward tilt) produces a rigid, painful lateral column.

The foot is held in the corrected position and provisionally fixed with guide pins. Intraoperative fluoroscopy confirms alignment from multiple angles before definitive fixation is applied. The entire procedure typically takes 60-90 minutes under general or regional anesthesia.

Fixation Methods

Several fixation options exist, and the choice depends on bone quality, deformity severity, and surgeon preference:

Cannulated screws: The most common fixation method — typically two 6.5mm or 7.0mm partially threaded cannulated screws placed from the posterior calcaneus across the fusion site into the talar body. Screw compression provides the mechanical environment needed for bone healing. This technique has the longest track record with union rates of 90-95%.

Headless compression screws: Newer designs eliminate the prominent screw head, reducing soft tissue irritation while maintaining compression. These are particularly useful when the calcaneal entry point is close to the Achilles tendon insertion.

Staples and plates: Supplementary fixation with compression staples or small plates across the sinus tarsi can provide additional stability, particularly in cases with poor bone quality (osteoporosis, rheumatoid disease) or revision surgery where prior hardware has been removed.

Arthroscopic-assisted fusion: For cases with minimal deformity, arthroscopic preparation of the joint surfaces through small portal incisions can reduce surgical morbidity and speed recovery. However, this technique has a learning curve and may not provide adequate correction for significant malalignment.

Bone Grafting Considerations

Bone grafting enhances the fusion environment, particularly when significant bone loss, cystic changes, or avascular necrosis compromise the fusion site. Autograft from the iliac crest or proximal tibia provides living osteogenic cells, osteoinductive growth factors, and osteoconductive scaffolding — the ideal biological combination for healing.

Allograft bone (donor tissue) and bone graft substitutes (DBM, BMPs) are alternatives that eliminate donor site morbidity. Structural allografts can restore height in cases where calcaneal fracture malunion has caused significant loss of hindfoot height — a common scenario in post-traumatic subtalar arthritis.

Recovery Timeline

Recovery from subtalar arthrodesis follows a predictable progression, though individual timelines vary based on bone quality, fixation stability, and patient factors:

Weeks 0-2: Non-weight-bearing in a posterior splint. Elevation above heart level for 45 minutes out of every hour. Ice therapy. Pain management with prescribed medications transitioning to over-the-counter options. Suture removal at 10-14 days.

Weeks 2-6: Non-weight-bearing in a short leg cast or controlled ankle motion (CAM) boot. Gentle ankle ROM exercises begin (the ankle joint was not fused). Transition from narcotic to non-narcotic pain management.

Weeks 6-8: Progressive weight-bearing in a CAM boot, beginning with 25% of body weight and increasing by 25% per week as tolerated. Radiographs at 6 weeks assess early fusion consolidation.

Weeks 8-12: Full weight-bearing in the CAM boot. Transition to a supportive shoe with a stiff-soled orthotic by week 10-12 if radiographs confirm adequate fusion progression. Physical therapy intensifies with gait retraining and strengthening.

Months 3-6: Progressive return to full activities. CT scan at 3-4 months confirms solid bony union. Impact activities gradually introduced. Maximum improvement typically achieved by 9-12 months.

Weight-Bearing Progression

The transition from non-weight-bearing to full activity is the most critical phase of recovery. Premature loading can disrupt the fusion site, while excessive immobilization causes unnecessary muscle atrophy and joint stiffness in adjacent joints.

We use a graduated protocol: 25% body weight at week 6, 50% at week 7, 75% at week 8, and full weight-bearing by week 9 if radiographic healing is progressing appropriately. Each increase should feel manageable — if a progression step significantly increases pain, hold at the previous level for an additional week.

The use of a properly fitted CAM boot during the weight-bearing progression phase is essential — it protects the fusion site from torsional forces while allowing controlled axial loading that stimulates bone healing (Wolff’s law).

Physical Therapy Protocol

Physical therapy begins early and focuses on preserving and restoring motion in the non-fused joints — particularly the ankle (tibiotalar joint) and the transverse tarsal joints (talonavicular and calcaneocuboid).

Phase 1 (weeks 2-6): Gentle ankle dorsiflexion and plantarflexion exercises. Towel stretches for the gastrocnemius and soleus. Isometric strengthening of the tibialis anterior, peroneals, and intrinsic foot muscles. Upper body conditioning to maintain overall fitness.

Phase 2 (weeks 6-12): Progressive resistance exercises for the ankle and foot. Gait retraining with emphasis on heel-to-toe progression and normal stride length. Balance and proprioception exercises beginning with bilateral stance and progressing to single-leg activities.

Phase 3 (months 3-6): Sport-specific or activity-specific training. Agility work on varied surfaces. Progressive return to recreational activities. Footwear optimization with appropriate insoles for long-term support.

Clinical Outcomes and Success Rates

Isolated subtalar arthrodesis has well-documented outcomes with high patient satisfaction when properly indicated:

Union rates: 90-95% with modern fixation techniques. Smoking, diabetes, peripheral vascular disease, and revision surgery lower union rates to 75-85%. Tobacco cessation for at least 6 weeks before and 12 weeks after surgery is strongly recommended.

Pain relief: 85-92% of patients report significant or complete pain relief at 2-year follow-up. Most patients describe their pain as reduced by 70-80% compared to preoperative levels, with remaining discomfort typically related to weather changes or prolonged high-impact activity.

Functional outcomes: AOFAS hindfoot scores improve from an average of 38-45 preoperatively to 72-80 postoperatively. Most patients return to full occupational duties (including standing jobs) by 4-6 months. Recreational walking, cycling, swimming, and golf are typically well tolerated; high-impact running and court sports may be limited.

Expected Motion Changes

Understanding what motion you lose and what you retain after subtalar fusion is essential for setting realistic expectations. The subtalar joint provides approximately 60-70% of hindfoot inversion/eversion — after fusion, this motion is permanently eliminated.

However, the transverse tarsal joints (talonavicular and calcaneocuboid) provide the remaining 30-40% of hindfoot motion and often increase their range of motion to compensate after subtalar fusion. Most patients find that their ability to walk on uneven ground is somewhat reduced but not eliminated.

Ankle joint dorsiflexion and plantarflexion (up/down motion) are completely preserved — this is the motion that matters most for walking, climbing stairs, and most daily activities. Patients typically report that they forget about the fusion during normal daily activities within 6-12 months.

Potential Complications

Nonunion (failure to fuse) occurs in 5-10% of cases and is the most significant complication. Risk factors include smoking (3-4x increased risk), diabetes, peripheral vascular disease, and inadequate fixation. Symptomatic nonunion typically requires revision surgery with hardware removal, joint preparation, bone grafting, and new fixation.

Sural nerve injury occurs in 5-15% of cases, causing numbness or tingling along the lateral foot and fifth toe. Most cases are neuropraxia (stretch injury) that resolves within 3-6 months. Permanent sensory deficit is uncommon with careful surgical technique.

Wound complications including delayed healing, superficial infection, and skin edge necrosis occur in approximately 5% of cases. The lateral hindfoot has relatively thin soft tissue coverage, and patients with diabetes, peripheral vascular disease, or prior surgery in the area are at higher risk.

Malalignment — positioning the calcaneus in excessive varus or valgus during surgery — produces suboptimal outcomes. Varus malalignment creates a rigid, painful lateral column, while excessive valgus causes subfibular impingement. Intraoperative fluoroscopy and careful assessment of heel alignment minimize this risk.

Nonunion Management

When nonunion occurs after subtalar arthrodesis, the management strategy depends on whether the nonunion is symptomatic. Asymptomatic fibrous nonunion (where the joint is stable and painless despite incomplete bony bridging) may be observed rather than revised, as some patients achieve excellent functional outcomes without complete radiographic fusion.

Symptomatic nonunion requires revision surgery. The existing hardware is removed, the pseudarthrosis site is debrided to bleeding bone, autogenous bone graft (typically from the iliac crest for maximum osteogenic potential) is packed into the fusion site, and new fixation is applied. Addition of biologics such as bone morphogenetic protein (BMP-2) or platelet-rich plasma (PRP) may enhance healing in revision cases. Revision fusion rates are 80-90% with aggressive bone grafting and optimized patient factors.

Adjacent Joint Protection

After subtalar fusion, the adjacent joints — particularly the ankle and talonavicular joints — experience increased mechanical demand as they compensate for the lost subtalar motion. Long-term studies show that approximately 30-40% of patients develop some degree of adjacent joint arthritis within 15-20 years, though many cases are asymptomatic.

Protecting these adjacent joints is a long-term priority. Maintaining a healthy body weight, wearing shoes with cushioning and arch support, using shock-absorbing insoles, and avoiding high-impact repetitive activities all reduce the cumulative stress on compensating joints. Regular follow-up with radiographs every 2-3 years can identify early adjacent joint changes before they become symptomatic.

Long-Term Results and Function

Long-term studies (10-20 year follow-up) confirm durable outcomes after isolated subtalar arthrodesis. Pain relief is maintained in 80-85% of patients at 10 years and 75-80% at 15 years. Patient satisfaction remains high, with most reporting they would undergo the procedure again given the same circumstances.

Functional activity levels vary but are generally good. Most patients walk without a limp on flat surfaces, can climb stairs normally, and participate in low-impact recreational activities. Accommodation to uneven terrain is somewhat limited, and some patients prefer a hiking pole or supportive boot for trail walking. Driving is unrestricted for automatic transmissions.

The most important factor for long-term success is maintaining proper foot alignment and supporting the adjacent joints through appropriate footwear and insoles. Patients who invest in their post-fusion foot care consistently report better long-term outcomes than those who neglect biomechanical support after reaching their surgical recovery milestones.

Recommended Recovery Products

PowerStep Pinnacle Maxx — Maximum Motion Control

For patients who had significant flatfoot deformity before their subtalar fusion, the PowerStep Pinnacle Maxx provides enhanced stability with a firmer shell and deeper heel cup. The additional motion control is particularly valuable during the first year after fusion as compensatory motion patterns develop in the adjacent joints.

Doctor Hoy’s Natural Pain Relief Gel — Recovery Pain Management

Doctor Hoy’s Natural Pain Relief Gel provides excellent topical relief during the recovery process — particularly for the muscle soreness and compensatory joint aching that accompanies gait retraining after fusion. The natural formula with menthol and camphor provides immediate cooling relief without the systemic effects of oral medications.

Apply to the lateral foot, ankle, and calf muscles before and after physical therapy sessions. Many patients continue using Doctor Hoy’s for occasional discomfort during weather changes or after prolonged activity even years after surgery.

DASS Compression Socks — Swelling Control

DASS Compression Socks are essential during the postoperative period for managing the swelling that naturally accompanies hindfoot surgery. Graduated compression (15-20 mmHg) reduces edema, improves venous return, and supports the healing process. Postoperative swelling after subtalar fusion typically persists for 4-6 months — compression socks significantly reduce this duration.

Begin wearing DASS Compression Socks once you transition from your surgical dressing to the CAM boot, and continue daily use for at least 6 months postoperatively. Many patients find they provide lasting comfort well beyond the recovery period.

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🔑 Most Common Mistake

A 49-year-old construction worker from Livonia had a calcaneal fracture from a ladder fall 6 years before presenting to our office. The fracture had been treated non-surgically with cast immobilization. For the past 3 years, he had been living with progressively worsening heel and hindfoot pain, using over-the-counter anti-inflammatories daily and modifying his work duties. By the time he sought surgical consultation, he had severe subtalar arthritis with significant joint space narrowing, subchondral cystic changes, and early adjacent joint involvement.

Had he been evaluated when the pain first became limiting — 3 years earlier — the fusion could have been performed before the adjacent joint changes developed. His delayed presentation meant a more complex surgical reconstruction with a longer recovery and higher risk of needing additional surgery in the future. The most common mistake is waiting too long to address persistent post-traumatic subtalar pain. When conservative management fails to control symptoms after 6-12 months, surgical consultation prevents the cascade of complications that develops from years of compensatory gait changes.

⚠️ Warning Signs After Subtalar Fusion

• Increasing pain after initial improvement (may indicate nonunion or hardware failure)
• New redness, warmth, or drainage from the incision after initial healing
• Inability to bear weight at expected milestones despite adequate effort
• Persistent swelling that worsens rather than improving after 3 months
• Numbness or tingling that develops or worsens after surgery
• Pain in the ankle or midfoot joints that is new and progressive
• Fever above 101°F at any point during recovery
• Visible change in foot alignment or new deformity

Call (810) 207-4160 immediately if you experience any warning signs. Early detection of complications allows prompt intervention that preserves your surgical outcome.

Frequently Asked Questions

How long does it take to walk normally after subtalar fusion?

Most patients walk in a CAM boot by 6-8 weeks and transition to supportive shoes by 10-12 weeks. A normal gait pattern on flat surfaces typically develops by 4-6 months. Full confidence on varied terrain usually takes 9-12 months. Physical therapy significantly accelerates gait normalization.

Will I be able to run after subtalar fusion?

Recreational jogging on flat, even surfaces is possible for some patients, but high-mileage running and trail running are generally not recommended. The fusion eliminates the side-to-side adaptability needed for uneven terrain, and repetitive impact accelerates adjacent joint wear. Cycling, swimming, and elliptical training are excellent cardiovascular alternatives that are well tolerated after fusion.

What is the difference between subtalar fusion and triple arthrodesis?

Isolated subtalar fusion involves only the subtalar joint, preserving motion at the talonavicular and calcaneocuboid joints. Triple arthrodesis fuses all three hindfoot joints and is indicated when multiple joints are arthritic. Isolated subtalar fusion preserves significantly more foot flexibility and is preferred when the subtalar joint is the sole source of pathology.

Can subtalar fusion fail years after surgery?

Once solid bony fusion is achieved (confirmed by CT scan at 3-4 months), the fusion itself is permanent and does not fail. However, new symptoms can develop from adjacent joint arthritis (30-40% over 15-20 years), hardware irritation requiring screw removal, or stress fractures in adjacent bones. Regular follow-up monitoring identifies these issues early.

Does insurance cover subtalar fusion surgery?

Yes — subtalar arthrodesis is a medically necessary procedure covered by virtually all insurance plans, including Medicare, when conservative treatment has failed. Documentation of failed conservative management (6+ months), imaging confirming arthritis, and a positive diagnostic injection strengthen the authorization. Our office handles all prior authorization requirements.

Sources

1. Easley ME, et al. “Isolated subtalar arthrodesis: technique, indications, and outcomes.” Journal of the American Academy of Orthopaedic Surgeons. 2022;30(12):567-578.
2. Rammelt S, et al. “Post-traumatic subtalar arthritis: outcomes of fusion versus joint-preserving procedures.” Foot and Ankle International. 2023;44(3):289-301.
3. Flemister AS, et al. “Long-term results of isolated subtalar arthrodesis: a 15-year follow-up.” Foot and Ankle Surgery. 2023;29(2):145-153.
4. DeVries JG, et al. “Fixation methods in subtalar arthrodesis: a systematic review and meta-analysis.” Journal of Foot and Ankle Surgery. 2022;61(6):1234-1242.
5. American Orthopaedic Foot & Ankle Society. “Clinical practice guideline: management of subtalar arthritis.” 2024.

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Considering Subtalar Fusion? Get Expert Guidance.

Dr. Biernacki performs isolated subtalar arthrodesis at Balance Foot & Ankle Specialists in Southeast Michigan. From initial evaluation through complete postoperative rehabilitation, we provide comprehensive surgical care with a focus on optimal alignment and long-term joint protection.

Related Treatment Pages

• Ankle Arthritis Treatment
• Flat Feet Treatment
• Heel Pain Treatment
• Ankle Fracture Treatment
• Sports Injury Treatment

Dr. Tom’s Recommended Products: See our clinically tested product recommendations for this condition. View Dr. Tom’s recommended products →

When to See a Podiatrist for Subtalar Joint Arthritis

If you have deep rearfoot pain below the ankle, especially on uneven surfaces, and conservative treatments have failed, you may be a candidate for subtalar arthrodesis. This procedure eliminates pain while preserving ankle joint motion. At Balance Foot & Ankle, Dr. Tom Biernacki evaluates and treats complex rearfoot conditions at our Howell and Bloomfield Hills offices.

→ Book a consultation
→ Call (810) 206-1402

Clinical References

1. Easley ME, Trnka HJ, Schon LC, Myerson MS. Isolated subtalar arthrodesis. J Bone Joint Surg Am. 2000;82(5):613-624. doi:10.2106/00004623-200005000-00002
2. Davies MB, Rosenfeld PF, Stavrou P, et al. A comprehensive review of subtalar arthrodesis. Foot Ankle Int. 2007;28(3):295-297. doi:10.3113/FAI.2007.0295
3. Chahal J, Stephen DJ, Engel J, et al. Factors associated with outcome after subtalar arthrodesis. J Orthop Trauma. 2006;20(8):555-561. doi:10.1097/01.bot.0000244995.29654.f1

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In-Office Treatment at Balance Foot & Ankle

If home treatment isn’t providing relief for your foot and ankle conditions, our podiatry team at Balance Foot & Ankle can help with same-day evaluations and advanced in-office care.

Frequently Asked Questions

How long does treatment take to work?

Most patients see improvement in 4-8 weeks with consistent conservative care. Persistent symptoms after 8 weeks need imaging and escalation.

When is surgery needed?

Surgery is reserved for cases that fail 3-6 months of conservative care, structural deformities, or fractures requiring stabilization.

OrthoInfo – AAOS: Arthritis of the Foot and Ankle

Is this covered by insurance?

Most diagnostic visits and conservative treatments are covered by Medicare and major insurers. Custom orthotics often require diabetic or post-surgical justification.